Wallace
T. Miller,
Jr, MD
Cryptococcal with AIDS:
#{149} Jonathan
1990;
O
#{149} Wallace
pulmonary
infec-
tions and
are a major source of mombidity mortality in patients with acquired immunodeficiency syndrome (AIDS). In several series of patients with AIDS who had pneumonia, cryptococcal pneumonia represented 2%-15% of all cases (1-4). Little has been written about the manifestations and radiographic appearance of cnyptococcal pulmonary infections in patients with AIDS. We report here our findings from seven cases.
METHODS We retrospectively biologic
and
reviewed
cytologic
the
records
micro-
at three
in-
stitutions (the Graduate Hospital of Philadelphia, the Hospital of the University of Pennsylvania, and the Veterans Administration
Center
to find
patients in whom had been identified
cultures choalveolar
viewed
or cytologic lavage
Cryptococcus from then
medical to identify who had
Patients
were
neolung of bronre-
records
and
those paa pulmonary
considered
to
cryptococcal pulmonary infection had both pulmonary symptoms
(cough, diographic
dyspnea) findings
be isolated
from the lung ing cytologic pies and cultured (cerebrospinal tients another
of Philadelphia)
examination fluid. We
radiographs with AIDS
infection.
could
Hospital
the patients’
chest tients
have they
175:725-728
T. Miller,
Infection Appearance’
PPORTUNISTIC
formans
meningitis.
Index terms: Acquired immunodeficiency syndrome (AIDS), 60.2518 #{149} Cryptococcosis, 60.2054 #{149} Lung, infection, 60.2054 #{149} Meningitis, 10.2054 Radiology
MD
Pulmonary Radiographic
The clinical, laboratory, and radiographic findings in seven patients with acquired immunodeficiency syndrome (AIDS) and cryptococcal pulmonary infections were reviewed. The infection was most commonly seen on radiographs as lymphadenopathy, interstitial infiltrates, or both. Interstitial infiltrates were commonly nodular. Large nodules or alveolar infiltrates, the most common findings at presentation in both immunocompetent patients and immunocompromised patients without AIDS, were not present in our series. Isolated pleural effusion was seen as the only radiographic finding in one case. Meningitis was present in six of seven cases and was neurologically silent in five of six cases. Cryptococcal pneumonia in AIDS patients should prompt a search for neurologically silent cryptococcal
M. Edelman,
and
abnormal chest and if C neoformans
by means
or could evaluation fluid
were excluded pathogen
be
ra-
of culture identified of the lung
from other body [CSF], blood). was
if
from our isolated
review from
dunsamfluids Paif the
RESULTS
From
the
Departments
of Radiology
(W.T.M., Jr, W.T.M.) and Medicine (J.M.E.), Hospital of the University of Pennsylvania, 3400 Spruce St. Philadelphia, PA 19104. Received October 24, 1989; revision requested November 20; revision received January 18, 1990; accepted January 23. Address reprint requests to W.T.M. © RSNA, 1990
in Patients
ding yeast, characteristic of C neoformans, was detected at cytologic evaluation of the BAL fluid from three others. These patients also had CSF cultures that were positive for C neo-
f onmans.
Among the two patients who did not undergo bronchoscopy, C neofonmans was cultured from the pleural fluid, blood, and CSF of one. In the other, a sputum Gram stain revealed yeast, and C neoformans was cultured from the blood and CSF. In addition, this patient had a diffuse rash, shown by means of histologic evaluation to be secondary to cryptococcal infection of the skin. The clinical data, means of diagnosis, and chest radiographic patterns of the seven patients are summarized in the Table. Presenting symptoms were nonspecific; all patients had feyen, three had dyspnea, three had cough, and two had diarrhea. One patient had lost weight, another had a skin rash, and a third patient was confused and ataxic. Arterial blood gas results were available for six of seven patients. Most patients had an elevated alveolar-arterial gradient, which indicated pulmonary parenchymal disease. Interstitial infiltrates with adenopathy were present in two patients (Fig 1); interstitial infiltrates alone were present in two patients (Figs 2, 3); and findings of hilam and/or mediastinal lymphadenopathy without infiltrates were present in two patients.
that
lung.
1
MD
Seven men with AIDS (aged 20-58 years) met the criteria for cryptococcal pulmonary infection. In five patients, specimens of bronchoalveolar lavage (BAL) fluid obtained at bronchoscopy yielded results positive for cryptococcal organisms. C neofonmans was cultured from the BAL fluid obtamed from two patients, and bud-
Of the demonstrated
four
chest radiognaphs interstitial infil-
trates, two showed pattern, somewhat any tuberculosis,
a diffuse nodular resembling milialthough the nod-
ules
and
fined showed
were
(Fig
larger
slightly
less
2). One chest radiograph focal nodular interstitial
de-
in-
Abbreviations: AIDS = acquired immunodeficiency syndrome, BAL = bronchoalveolar Iavage, CSF = cerebrospinal fluid, CNS central nervous system, TB tuberculosis.
725
Clinical,
Laboratory,
and Radiographic
Findings
in Seven
Patients
with
AIDS
and Cryptococcal
Pulmonary
Infections
Arterial
Blood Cases Patient
Duration
No/Age
Risk
(y)
Recovery
Factors
Status
Symptoms
H
R
Dyspnea, cough
2/25
H, IVDA
D
3/28
NA
R
4/29
H
D
Fever, chills, cough, diarrhea Dyspnea, fever, arrhea Fever, dyspnea, cough, rash
5/58
H
D
6/35
IVDA
R
7/46
H
R
Note.-BAL intravenous
=
drug
bronchoalveolar abuse, NA
with
amphotenicin
B.
DISCUSSION C neoformans is a nonmycelial budding yeast found in soil contaminated by pigeon or chicken excreta. Although it rarely causes pulmonary infections in humans, of those infected, 50%-80% are immunocompromised hosts (5). Cryptococcal infec-
Radiology
#{149}
di-
tion,
Hg)
at Presentation
78
BAL,
2 wk
7.47
29
99
BAL,
CSF